Part IV Quality Improvement Activity Application

Title of QI Activity

Sponsor Organization Please provide name and mailing address Start Date of QI Activity End Date of QI Activity

Upon approval, the following information will be included on the ABOG MOC website, unless otherwise specified by the applicant.

Project Representative Name & Title Project Representative Email Project Representative Phone Number Project Website

Activity Overview:

Yes No Not applicable Addresses care the physician can influence in one or more of the six Institute of Medicine quality dimensions (safety, effectiveness, timeliness, equity, efficiency, ☐ ☐ ☐ and/or patient-centeredness)

Explanation

Have a specific, measurable, specialty-relevant and time-appropriate aim for improvement ☐ ☐ ☐

Explanation

Use of appropriate, relevant and evidence-based performance measures that include measurement related to patient care at the appropriate unit of analysis ☐ ☐ ☐

Explanation Includes appropriate interventions (education, reminders, checklists, registries, etc.) to be tested for improvement ☐ ☐ ☐

Explanation

Includes appropriate prospective and repetitive data collection and reporting of performance data to support effective assessment of the impact of the ☐ ☐ ☐ interventions over 2 or more improvement cycles

Explanation

Represents an attempt at translation or implementation of an improvement into routine care or the dissemination or spread of an existing improvement into ☐ ☐ ☐ practice

Explanation

Possesses sufficient and appropriate resources to support the successful conclusion of the activity without introducing a real or perceived conflict of interest. Please reference attached MOC Conflict of Interest Policy for ☐ ☐ ☐ additional guidelines.

Explanation

Describe how you will determine that physicians are meaningfully participating in the QI activity. A QI activity is considered meaningful when: 1. The activity is intended to provide a clear benefit to the physician’s patients and impact the physician’s clinical practice; 2. The physician is actively involved in the activity; 3. The physician is able to personally reflect on the activity, the change that occurred in their practice and how it affected the way care is delivered.

Explanation Please attach any relevant files regarding the Quality Improvement (QI) Activity that you wish to share with the reviewers. Please provide explanations for requirement areas. Relevant files can be attached to answer any of the requirement areas.

As the project representative, I accept responsibility for managing this activity in compliance with the standards and requirements of the American Board of Obstetrics and Gynecology:

 Maintaining Standards: I will ensure that our QI activity maintains the ABOG standards for QI activities for MOC.  Attestations: I will attest to the participation of individual physicians. Or, I will assure that organizational sponsors are designated to attest to the participation of individual physicians for MOC credit. I will ensure that the names and ABOG identification numbers of participants completing the QI activity will be transmitted to ABOG.  Conflict of Interest: I will ensure that this QI activity does not violate the ABOG Conflict of Interest Policy and communicate any changes in commercial support that may require additional review by the ABOG.  Certification Period: I understand that if this QI activity is approved for MOC credit, the activity will be approved for two years or the length of the project, whichever is shorter. I understand that I must submit for re-approval after a period of two years if I would like this QI activity to continue to be utilized for MOC credit.

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